Record of Investigation into Death (Without Inquest)

Coroners Act 1995
Coroners Rules 2006
Rule 11 

I, Timothy John Hill, Coroner, having investigated a death of 

Monty William TROTTER


Find That:- 

Monty William TROTTER died on or about the 4 of September 2006 at National Pacific Rail, 35 Hobblers Bridge Road, St Leonards. 

Monty William TROTTER was born in Launceston on the 12 of April 1955 and at the time of his death he was aged 51 year(s). 

Monty William TROTTER was married and his occupation at the date of his death was a maintenance labourer.

I find that the deceased died as a result of: Chest Injuries due to being run over by train wagon wheel during shunting. 

At the time of the deceased persons death he was not being treated by a medical practitioner.

Pursuant to the provisions of Section 26A(3) of the Coroners Act 1995 I have decided that it would not be contrary to the public interest nor would it be in the interests of justice to hold an inquest into Mr Trotters death. I have made this decision having reviewed the evidence and receiving representations from the family of Mr Trotter.

Circumstances Surrounding the Death : - 

Mr Trotter was 51 years and had been employed in the Tasmanian rail industry for the past 30 years. He was born and married in Launceston and is survived by his wife Carol and their three children.

Pacific National Tasmania was part of the Inter-Modal Division of the parent company, Pacific National Pty Ltd at the time of Mr Trotters death. Pacific National Tasmania (PNT) operated a rail depot at 35 Hobblers Road, Newstead. The rail depot included a repair workshop. The workshop area allowed for both heavy & light repairs on the railway rolling stock. Mr Trotter was a wagon repairer working on the light line. 

On Monday the 4 September, 2006 Mr Trotter was working with Mr Kerry Newton (employee of PNT) undertaking inspections and repairs on rolling stock on the One Spot Repair Line just outside the roller door entrance into the wagon repair workshop. At about 10-30am that morning, Mr Trotter and Mr Newton were inspecting the underframe of Wagon QS5X while it was situated at the northern end of a rake of 10 wagons stationed on the One Spot Repair Line. Mr Trotter was lying under the front left hand of the wagon. Mr Newton was lying under the front right hand end of the wagon. Both men were inspecting the draft gear for repairs when wagon QS5X moved forward unexpectedly, pinning Mr Trotter beneath the front left hand wheel resulting in his death. Mr Newton managed to escape without injury as he saw the wagon wheel move and was able to move clear of the danger.

Wagon QS5X moved due to the shunting of another wagon onto the rake of 10 wagons. On the day of the incident, Mr Martin Parry (employee of PNT) was moving a shunt tractor in order to move other wagons that had been left in the yard for repair. Mr Parry was attempting to move the wagons into the Heavy Wagon repair section of the workshop. Mr Parry had already undertaken repairs to one (1) wagon and was in the process of bringing the next wagon into the workshop. However, as the wagon required was in the middle of a series of wagons, he had to shunt the first wagon onto the One Spot Repair line in order to access the middle wagon. Unfortunately, unknown to Mr Parry, Mr Trotter and Mr Newton were lying underneath the first of 10 wagons already stationed on the One Spot Repair line carrying out an inspection. Mr Parry has shunted the wagon onto the One Spot repair line which has moved the wagon where both Mr Trotter and Mr Newton were lying. Mr Trotter was caught under the moving wagon and was pushed approximately 18 inches along the rail line. Mr Trotter died as a result of injuries received from this incident.

Pacific National Tasmania had a large volume of Standard Operating Procedures including Local Safety Notice Tas Rail No. 1404 (dated the 19 August, 2004) which set out the procedure to be followed when shunting wagons not attached to a locomotive.

The Department of Infrastructure, Energy and Resources Rail Safety Unit, Workplace Standards Tasmania and Tasmania Police conducted a comprehensive investigation into the circumstances surrounding the death of Mr Trotter. The investigation involved the interviewing of witnesses, scene examination and the review of safety operations in respect to the movement of rolling stock at the rail depot at Newstead.

Mr Newton states that,

"Monty has been employed for at least the past 30 years and I have worked with him for the past 15 months on repairing the wagons. We repair wagons from all around the State with Newstead being the main repair depot. The wagons come into the yard with a repair card on them. Today we had just repaired a slack adjuster arm which is part of the braking system.

I went to our wagon on the line which had a card indicating worn draft gear A end. This means the opposite end to the handbrake end. We needed the shunter to push this wagon into the shed to start repairs. The shunter was being used by Martin Parry on his line which was parallel to ours. He was moving wagons.

While we were waiting for the shunter, I looked under the B end because the A end was faulty. We always check the B end and make sure it isnt worn otherwise both ends are replaced while the wagon is here. I noticed it was worn and thought it might be worth replacing this end also.

I said to Monty its not too bad and we both went under for a second look. This is what we normally do. We would have both been lying over the rail; his back was against the outer wheel facing away from the centre of the carriage. I was lying on my right side facing the centre of the carriage.

While we were inspecting the draft gear, the carriage started to move towards us. I cant remember how I got out but I did as quickly as I could. Monty had yelled as soon as the carriage started to move but I cant remember what he said or whether it was a yell of pain but it could have been. The carriages generally dont move as it is slightly uphill to the workshop and generally a shunt is only bumping the carriages together. Monty sort of slid along the rail in front of the wheel for about 18 inches. I said, You alright Monty but he didnt answer. I didnt want to move him and it looked like he was pinned by the wheel. I ran up to the workshop and grabbed Paul. I got a crane to push the wagons back. Paul went to Monty and another guy, Mathew Gamble said he would call the ambulance."

Mr Parry commenced work at 7:00am on the day of the incident. Mr Parry was to carry out maintenance on wagons located on the heavy repair track. Having completed repairs to a wagon he commenced to shunt a number of wagons back up his line. Mr Parry uncoupled a wagon and began to shunt the wagon onto the line where Mr Trotter and Mr Newton generally undertake wagon repairs. Mr Parry states that, 'I gave the wagons a full shunt from on the line the tractor was in low gear. I chose to shunt like this as a fly shunt would have been too forceful as I was worried about the bay door as it was closed. I shunted them forward until I felt the rear wagons come into contact with the forward wagon. I then went back to shunt my wagon up my line. I changed the points and fly shunted my wagon up my line. I followed the wagon up on the tractor and I then got back on the line when I saw a few people around the wagon at the front of Monty and Cats line. I also saw a crane there…..when I (later) saw Monty he was grey and I felt terrible…I was devastated.' 

Toxicology testing conducted by Mr Andrew Griffiths of Forensic Science Service Tasmania indicated the Mr Trotter had no apparent significant toxicology. An analysis conducted of a blood sample obtained from Mr Parry indicated negative results in respect to both alcohol (ethanol) and drug screening.

A report by Dr Lawrence (Pathologist) found that Mr Trotter died from 'chest injuries due to being run over by a train wagon during shunting.'

The investigation conducted by The Department of Infrastructure, Energy and Resources Rail safety Unit, Workplace Standards Tasmania and Tasmania Police made the following findings in respect to the circumstances surrounding the death of Mr Trotter.

  • Two wagon maintainers decided to inspect the underneath of the wagon QS 5/X on the One Spot Line outside the workshop without isolating the line in accordance with Safety Rules.

  • There was no written procedure for shunting wagons in the Wagon Repair area and into the workshop on the southern side of the shunting tractor however, there were established and written procedures for shunting wagons out of the workshop to the northern side.

  • There was no written requirement that the shunting of wagons into the Wagon Repair workshop be undertaken by a minimum of two staff. While it was usual practice for two staff to undertake this task, on the day of the incident only one person was shunting wagons in the Wagon Repair area.

  • Investigations indicate that Mr Trotter and Mr Newton knew that another wagon maintainer was shunting wagons at the southern end of the Wagon Repair area. However, they assumed that the shunting would not affect the wagon they were inspecting.

  • It was accepted practice by the wagon maintainers that handbrakes were not applied to wagons stabled on the One Spot Line. However, when Train Services staff deposited wagons in the Wagon Repair area, they followed Pacific National Tasmania (PNT) Code of Operating (COP) rules and applied handbrakes to a minimum number of wagons (the minimum number required was 3 in 10).

  • PNT COP rules did not apply to the movement of wagons by wagon maintainers in the Wagon Repair area.

  • PNT Safety Rules applied in the Wagon Repair area and all wagon maintainers were trained and certified in use of these rules.

  • PNT Local Safety Notice (06/06) was issued on the 14 June, 2006 and prohibited gravitational or loose shunting of wagons. There was general acceptance by the wagon maintainers that the instruction did not apply and loose shunting continued to be undertaken through the use of the shunting tractor contrary to this notice. The notice was issued only 2 months prior to Mr Trotters death.

  • PNT Local Safety Notice (14/04) was issued on the 19 August, 2004 and identified the procedures to be adopted for safely undertaking maintenance on rolling stock. The instruction outlined an isolation procedure including the use of flags and locks for locking switch points. However, it was the practice of wagon maintainers that the provisions of this safety notice were only complied with in situations where a wagon was repaired in operational areas.

  • There were conflicting views on the applicability of parts of the Safety Rules and Local Safety Notices as to the Wagon Repair area. However, it was accepted by the majority of senior managers interviewed that the provisions of Local Safety Notices applied in the Wagon Repair area. In any event, the views held by senior management in respect to the extent of the application of Local Safety Notices had not been adequately conveyed to the wagon maintainers who considered that they did not apply to the Wagon Repair area.

  • The wording and format of Local Safety Notices may have contributed to the confusion and may have been a factor in the views held by the wagon maintainers that they did not apply to the Wagon Repair area.

  • PNT Support Services Training and Compliance Team audited train services (operations) on a regular basis but did not audit maintenance areas. This task was left to local supervisors or other trained staff by way of safety observations.

  • Maintenance areas were required to conduct a certain number of safety observations per month. However, without an external auditing process it would appear that safety observations in isolation were insufficient to meet desired safety outcomes.

  • A task safety analysis was undertaken on 12 July 2005 in respect to the shunting of a wagon through the workshop. The analysis identified the risk of running over a person during the movement of the wagon. The analysis indicated that existing controls in place (including having two staff involved) mitigated against this risk.

  • Job briefings to all staff occurred at times but were usually in response to tasks that were considered out of the ordinary. Informal discussions were held between the wagon supervisor and wagon maintainers. However, there was no evidence found to suggest that a regular formal staff briefing was held where staff were informed of about what each other was doing.

  • Annual compliance audits were conducted by the Rail Safety Regulator and third party auditors in the five years prior to the death of Mr Trotter. Those audits did not review compliance with procedures and safety instructions in the Wagon Repair area.

  • The action by the two wagon maintainers in lying underneath the wagon and across the rails without following procedures and rules specifically designed to ensure that proper safety protection was in place prior to placing themselves within the profile of a wagon, contributed to the accident. Proper protection in this case would have involved locking the switch points and placing red flags at the far end of the rake of wagons. This would have provided a warning to the driver of the shunting tractor that someone was working on a wagon.

  • The application of the appropriate number of handbrakes on the wagons stabled on the One Spot Line would have reduced the probability of this incident occurring.

  • The use of two people during the shunting process may have reduced the probability of this incident occurring.

  • PNT failed to ensure compliance with Local safety Notices 14/04 & 06/06 in the Wagon Repair area.

  • PNT failed to undertake a risk assessment on the movement of wagons using the shunting tractor with the introduction of Local Safety Notice 06/06 and how the provisions of the notice were to be applied in the Wagon Repair area.

As a result of this incident and in response to a verbal and written Prohibition Notice issued pursuant to the provisions of section 38 of the Workplace Health & Safety Act 1995 Pacific National Tas Services Pty Ltd undertook the following remedial action.

  • The appointment of an Operations Safety Manager.

  • Implementation of a form on which to record morning job briefings in the Wagon Repair area.

  • Implementation of an audit process for the Operations Safety Manager to ensure job briefings are being conducted.

  • Development and issue of Local Operating Procedure PNT-LOPRS2 (East Tamar Junction Wagon Repair facility Inspection and Shunting Procedure). This notice describes the provision of protection against unauthorised movement of wagons, unauthorised coupling of rakes of wagons subject to maintenance, accidental movement of wagons by mobile plant or equipment and injury to Pacific National Tasmania employees and/or contractors whilst attending to wagon repairs/inspections.

  • The training of staff in Local Operation Procedure PNT-LOP-RS2.

  • The development and implementation of Local Operating Procedure PNT-LOP-RS1 (Carrying out maintenance of rolling stock). The notice provides work procedures for the protection of person/s whilst working on, near or under rail wagons and/or rolling stock. The procedure covers the use of locks and lock out tags, removal of lock out tags, fitting of red flags/lights and the securing of wagons by engaging handbrakes.

  • The training of staff in Local Operating Procedure PNT-LOP-RS1.

  • The shunt tractor was replaced by a rail mounted specialised unit called a Tug. The Tug is fitted with a coupler so it can be physically connected to the wagons being shunted.

  • On 21st September, 2006 wagon maintainers within the Wagon Repair area undertook training and accreditation in operating the Tug.

  • The development and issue of Local Safety Notice 10/06 (Protection of workmen carrying out rolling stock maintenance). The notice informs Pacific National Tasmania personnel about improvements in the companys procedures in respect to undertaking rolling stock maintenance.

  • The development and issues of Local Safety Notice 11/06 Advice to staff on the update to Code of Practice Rules relating to work being conducted on rolling stock.

  • The fitting of additional derailers.

  • Removal of obsolete equipment to improve working areas and sight visibility.

  • The purchase of additional radios to improve communication during shunt movements.

  • Initiate an ongoing review of internal audit and inspection processes and the updating of the risk register.

On the 15 December, 2006 representatives from the Department of Infrastructure, Energy and Resources Rail safety Unit and Workplace Standards Tasmania conducted a site visit at Pacific Nationals Tasmania rail depot at 25 Hobblers Bridge Road, Newstead to view work practices in the Wagon Repair area. This process included a practical demonstration of processes and procedures that were developed and implemented by Pacific National Tasmania since the death of Mr Trotter. In addition to the practical demonstration, 'staff were questioned on their knowledge of the new work procedures and whether or not they believed that all the procedures had improved the level of safety within the Wagon Repair area. All those questioned agreed the new procedures improved the level of safety in the area' (Joanne Hendley, Senior Inspector Workplace Standards Tasmania).

Comments & Recommendations:-

I find that a combination of inaction by Pacific National Tasmania in regards to enforcing and monitoring safety procedures and processes that were applicable to maintenance activities in the Wagon Repair workshop area, misinterpretation of those safety procedures and processes by the wagon maintainers themselves, together with the actions of Mr Trotter and his fellow worker were all contributing factors in the chain of events that led to the tragic death of Mr Trotter.

I note that since the 4 September, 2006 Pacific National Tasmania have taken action to improve the safety of its operations in the area of the Wagon Repair workshop. These new processes and procedures were reviewed by Workplace Standards Tasmania and Department of Infrastructure, Energy and Resources Rail safety Unit on the 15 December, 2006.

I note that Pacific National Tasmania pleaded guilty to two (2) offences under the Workplace Health & Safety Act 1995 in the Launceston Magistrates Court on the 24 January, 2008 and was fined $30,000.

I recommend that the annual compliance audits conducted by the Rail Safety Regulator include a compliance audit of procedures and safety instructions for the Wagon Repair area.

I recommend that Pacific National Tasmania conduct regular formal Staff Briefings concerning Safety Notices, compliance practices and procedures.

I recommend that an audit system be developed by the Rail Safety Union to ensure that Pacific National Tasmania conduct briefings on a regular and ongoing basis.

Before I conclude this matter, I wish to convey my sincere condolences to the family of the deceased.

This matter is now concluded

DATED : Wednesday, 20 January 2010 at Launceston in the state of Tasmania.


Timothy John Hill